medwireNews: Giving people a deadline in the invitation letter for fecal immunochemical test (FIT) colorectal screening makes the kit return timely and reduces the need for reminder letters, the TEMPO study indicates.
“A deadline for FIT return is a highly cost-effective intervention that could be easily implemented in routine practice through adding a single sentence to the invitation letter, increasing screening uptake and preventing colorectal cancer deaths,” write Kathryn Robb (University of Glasgow, UK) and colleagues in The Lancet.
The study enrolled 39,734 people who were eligible for colorectal screening (mean age 61.2 years, 50.1% women). This included individuals aged 50–74 years who had not opted out of the screening program; individuals aged 75 years and older who had opted into the program; those with a Community Health Index Number who were due to be sent a FIT; and those who had completed their last FIT more than 2 years ago.
The participants were randomly assigned to receive a letter of invitation for FIT colorectal screening with no suggested FIT return deadline (group 1); a 1-week deadline (group 2); a 2-week deadline (group 3); and a 4-week deadline (group 4); or to receive a letter with no deadline, a 1-week, 2-week, or 4-week deadline along with a problem-solving planning tool (groups 5–8, respectively).
The tool was designed to help participants identify and overcome potential concerns with completing the FIT.
Reminder letters were sent around 6 weeks after the initial invitation if the FIT had not been returned, and a subsample of participants were mailed a patient participant involvement informed acceptability survey.
The primary outcome of the study was the proportion of FITs returned that resulted in a positive or negative result within 3 months.
A total of 66.0% of participants in group 1 returned their FIT within 3 months compared with rates of 66.0%, 68.0%, and 66.8% in groups 2, 3, and 4 respectively. Among participants given a planning tool, 63.2% of group 5 returned their FIT compared with higher rates of 67.9%, 67.1%, and 67.2% in groups 6, 7, and 8, respectively.
Overall, FIT return was significantly more likely among recipients given any deadline compared with no deadline, with an adjusted odds ratio (aOR) of 1.13 after considering age, sex, sociodemographic quintile, and urban–rural classification. However, participants given a planning tool were no more likely to return their FIT than those without the tool, with a nonsignificant aOR of 0.98.
Robb et al found a significant interaction between deadlines and planning tools when comparing a deadline versus no deadline as a binary comparison, but this was driven by the particularly low return rate in group 5, the authors say.
Specifically, while there was no evidence that a planning tool had an impact on FIT return rates among participants who were given a deadline (aOR=1.02), receipt of a planning tool without a deadline (significant aOR=0.88) “appeared detrimental,” the researchers say.
For the secondary outcome of whether a usable FIT was returned within 4 weeks or a reminder letter was required, including a deadline significantly reduced the need for the latter, with an aOR of 0.83, whereas the planning tool had no effect. Giving a deadline of 2 weeks particularly reduced the need for reminder letters, with a rate of 40.0% versus 44.6% with no deadline.
“The intervention effects might be considered small, although adding a deadline to the invitation letter is a near zero-cost intervention delivered at national scale,” write Robb and colleagues. They estimate that a 2% increase in FIT returns would mean a further 39,000 people participating in a screening round and an additional 23 colorectal cancer deaths being avoided, with the 78,000 fewer reminder letters needing to be sent resulting in “a considerable saving of costs.”
The investigators also suggest that a 2-week deadline “might strike a good balance between urgency (promoting rapid returns) and leniency (reducing the number who miss the deadline).”
According to the results of the acceptability survey, both the deadline and planning tool interventions were rated as acceptable or completely acceptable by more than 80% of participants in the exposed groups, and the deadline was seen as more acceptable than the planning tool.
In an editorial related to the study, Hermann Brenner and Michael Hoffmeister, both from the German Cancer Research Center in Heidelberg, write that, “[g]iven the widespread and increasing implementation of FIT-based colorectal cancer screening programmes in many countries, these results are of high relevance on a global scale, because they appear to be generalisable to many non-Scottish populations.”
The extra resources needed for the TEMPO trial “must have been exceptionally low,” they observe, and similar approaches could be used in other ways to improve cancer screening, such as “optimisation of invitation materials and logistics, novel approaches to better reach more deprived and typically less adherent population groups, or novel approaches of risk-adapted screening strategies.”
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Lancet 2025; doi:10.1016/S0140-6736(24)02813-7
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